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Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty

Mont, Michael A. MD; Jacobs, Joshua J. MD; Boggio, Lisa N. MS, MD; Bozic, Kevin John MD, MBA; Della Valle, Craig J. MD; Goodman, Stuart Barry MD, PhD; Lewis, Courtland G. MD; Yates, Adolph J. Jr MD; Watters, William Charles III MD; Turkelson, Charles M. PhD; Wies, Janet L. MPH; Donnelly, Patrick MA; Patel, Nilay MPH; Sluka, Patrick MPH

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: December 2011 - Volume 19 - Issue 12 - p 768–776
AOS Clinical Practice Guideline Summary

This guideline supersedes a prior one from 2007 on a similar topic. The work group evaluated the available literature concerning various aspects of patient screening, risk factor assessment, and prophylactic treatment against venous thromboembolic disease (VTED), as well as the use of postoperative mobilization, neuraxial agents, and vena cava filters. The group recommended further assessment of patients who have had a previous venous thromboembolism but not for other potential risk factors. Patients should be assessed for known bleeding disorders, such as hemophilia, and for the presence of active liver disease. Patients who are not at elevated risk of VTED or for bleeding should receive pharmacologic prophylaxis and mechanical compressive devices for the prevention of VTED. The group did not recommend specific pharmacologic agents and/or mechanical devices. The work group recommends, by consensus opinion, early mobilization for patients following elective hip and knee arthroplasty. The use of neuraxial anesthesia can help limit blood loss but was not found to affect the occurrence of VTED. No clear evidence was established regarding whether inferior vena cava filters can prevent pulmonary embolism in patients who have a contraindication to chemoprophylaxis and/or known VTED.

From the Rubin Institute for Advanced Orthopedics and the Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD (Dr. Mont), Department of Orthopedic Surgery (Dr. Jacobs) and Division of Hematology and Oncology (Dr. Boggio), Rush University Medical Center, Chicago, IL, Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA (Dr. Bozic), Midwest Orthopaedics at Rush, Rush University Medical Center (Dr. Della Valle), Department of Orthopaedic Surgery, Stanford School of Medicine, Stanford University, Redwood City, CA (Dr. Goodman), Orthopedic Associates of Hartford, Hartford, CT (Dr. Lewis), Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA (Dr. Yates), Bone and Joint Clinic of Houston, Houston, TX (Dr. Watters), and the Department of Research and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL (Dr. Turkelson, Ms. Wies, Mr. Donnelly, Mr. Patel, and Mr. Sluka).

Dr. Mont or an immediate family member has received royalties from Stryker; serves as a paid consultant to Johnson & Johnson, Joint Active Systems, Salient Surgical, Stryker, and TissueGene; and has received research or institutional support from National Institutes of Health (NIAMS and NICHD), Stryker, TissueGene, and Wright Medical Technology. Dr. Jacobs or an immediate family member serves as a paid consultant to Johnson & Johnson, Medtronic Sofamor Danek, Smith & Nephew, SpinalMotion, and Zimmer; serves as an unpaid consultant to Implant Protection; owns stock or stock options held in Implant Protection; and has received research or institutional support from Medtronic Sofamor Danek, SpinalMotion, and Zimmer. Dr. Boggio or an immediate family member is a member of a speakers' bureau or has made paid presentations on behalf of CSL Behring; has received research or institutional support from Baxter, Bayer, GTC, and Novo Nordisk; and serves as a board member, owner, officer, or committee member of the Hemophilia and Thrombosis Research Society. Dr. Bozic or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, Agency for Healthcare Research and Quality (AHRQ), American Association of Hip and Knee Surgeons, American Joint Replacement Registry, American Orthopaedic Association, California Joint Replacement Registry Project, California Orthopaedic Association, and the Orthopaedic Research and Education Foundation. Dr. Della Valle or an immediate family member serves as a paid consultant to Biomet, ConvaTec, and Smith & Nephew; serves as an unpaid consultant to CD Diagnostics; has received research or institutional support from Smith & Nephew and Stryker; and serves as a board member, owner, officer, or committee member of the American Association of Hip and Knee Surgeons and the Arthritis Foundation. Dr. Goodman or an immediate family member owns stock or stock options held in Accelalox, StemCor, and Tibion and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons and the Orthopaedic Research Society. Dr. Lewis or an immediate family member has received research or institutional support from Biomet and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Connecticut State Medical Society, and Hartford County Medical Association. Dr. Yates or an immediate family member serves as a board member, owner, officer, or committee member of the American Association of Hip and Knee Surgeons. Dr. Watters or an immediate family member has received royalties from Stryker; serves as a paid consultant to Palladian and Stryker; owns stock or stock options held in Intrinsic Orthopedics; and serves as a board member, owner, officer, or committee member of the American Board of Spine Surgery and the North American Spine Society. Ms. Wies or an immediate family member owns stock or stock options held in Merck/Schering-Plough. None of the following authors or any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Turkelson, Mr. Donnelly, Mr. Patel, and Mr. Sluka.

This clinical practice guideline was approved by the American Academy of Orthopaedic Surgeons on September 24, 2011.

The complete guideline, which includes all tables, figures, and appendices, is available at http://www.aaos.org/research/guidelines/VTE/VTE_guideline.asp

© 2011 by American Academy of Orthopaedic Surgeons
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